Long-term follow-up of a racially and ethnically diverse population of men with localized prostate cancer who did not undergo initial active treatment.

BACKGROUND: There is limited research on the racial/ethnic differences in long-term outcomes for men with untreated, localized prostate cancer. METHODS: Men diagnosed with localized, Gleason ≤7 prostate cancer who were not treated within 1 year of diagnosis from 1997-2007 were identified. Cumulative incidence rates of the following events were calculated; treatment initiation, metastasis, death due to prostate cancer and all-cause mortality, accounting for competing risks. The Cox model of all-cause mortality and Fine-Gray sub distribution model to account for competing risks were used to test for racial/ethnic differences in outcomes adjusted for clinical factors. RESULTS: There were 3925 men in the study, 749 Hispanic, 2415 non-Hispanic white, 559 non-Hispanic African American, and 202 non-Hispanic Asian/Pacific Islander (API). Median follow-up was 9.3 years. At 19 years, overall cumulative incidence of treatment, metastasis, death due to prostate cancer, and all-cause mortality was 25.0%, 14.7%, 11.7%, and 67.8%, respectively. In adjusted models compared to non-Hispanic whites, African Americans had higher rates of treatment (HR = 1.39, 95% CI = 1.15-1.68); they had an increased risk of metastasis beyond 10 years after diagnosis (HR = 4.70, 95% CI = 2.30-9.61); API and Hispanic had lower rates of all-cause mortality (HR = 0.66, 95% CI = 0.52-0.84, and HR = 0.72, 95% CI = 0.62-0.85, respectively), and API had lower rates of prostate cancer mortality in the first 10 years after diagnosis (HR = 0.29, 95% CI = 0.09-0.90) and elevated risks beyond 10 years (HR = 5.41, 95% CI = 1.39-21.11). CONCLUSIONS: Significant risks of metastasis and prostate cancer mortality exist in untreated men beyond 10 years after diagnosis, but are not equally distributed among racial/ethnic groups.

Assigning value to preparation for prostate cancer decision making: a willingness to pay analysis.

BACKGROUND: The Personal Patient Profile-Prostate (P3P) is a web-based decision support system for men newly diagnosed with localized prostate cancer that has demonstrated efficacy in reducing decisional conflict. Our objective was to estimate willingness-to-pay (WTP) for men's decisional preparation activities. METHODS: In a multicenter, randomized trial of P3P, usual care group participants received typical preparation for decision making plus referral to publicly-available, educational websites. Intervention group participants received the same, plus online P3P educational media specific to the user's personal preferences and values, and a communication coaching component tailored to race\ethnicity, age and language. WTP data were collected one week after physician consultation. An iterative bidding direct contingent valuation survey format was used, randomly assigning participants to high or low starting values (SV). Tobit models were used to explore associations between SV-adjusted WTP and age, education, marital and work-status, insurance, decision-control preference and decision-making stage. RESULTS: Of 392 participants enrolled, 141 P3P and 107 usual care (UC) provided a WTP value. Men were willing to pay a median $25 (IQR $10-100) for P3P in addition to usual care preparation materials. In the final multivariable tobit regression model, SV, marital status, stage of decision making and income were significantly associated with WTP for P3P. Decision control preference was considered marginally significant (p = 0.11). Men were WTP a median $30 (IQR $10-$200) for usual care material alone. In the final multivariable model, SV, education, and stage of decision making were significantly associated with WTP in usual care. CONCLUSION: WTP was similar for UC and for the addition of P3P to UC decision preparation. The WTP values were associated with demographic and preference variables. Findings can help focus decision support on future patients who would benefit most: those without strong support systems, at earlier stages of decision making, and open to a shared-decision style. TRIAL REGISTRATION: NCT NCT01844999 . Registered May 3, 2013.

Osteoporosis management program decreases incidence of hip fracture in patients with prostate cancer receiving androgen deprivation therapy.

OBJECTIVE: To evaluate the incidence of hip fracture in men with prostate cancer receiving androgen deprivation therapy (ADT). MATERIALS AND METHODS: One of the detrimental side effects of ADT for prostate cancer is osteoporosis. Through an osteoporosis prevention program implemented in our healthcare system, the patients at risk undergo dual x-ray absorptiometry scans and receive treatment if the T-score indicates bone loss. We evaluated the incidence of hip fracture in men with prostate cancer who were receiving ADT through a retrospective, cohort study conducted within a managed care organization. The participants were all men newly diagnosed with prostate cancer from January 2003 to December 2007 receiving leuprolide injections. Patients who had had a dual x-ray absorptiometry scan beginning 3 months before the index date through the end of study were included in the intervention group; all others were included in the comparison group. The main outcome of interest was a hip fracture occurring after the index date, excluding cancer pathologic fractures, traumatic fractures, and fractures associated with epilepsy. RESULTS: A total of 1071 patients were in the intervention group, and 411 were in the comparison group. In the intervention group, 18 hip fractures occurred compared with 17 in the comparison group. The incidence rate of hip fractures per 1000 person-years was 5.1 (95% confidence interval 3.0-8.0) in the intervention group and 18.1 (95% confidence interval 10.5-29.0) in the comparison group. CONCLUSION: The incidence rate of hip fracture in this population was reduced >70% with enrollment in an osteoporosis management system, avoiding this morbid complication of ADT.

Rapid implementation of a robot-assisted prostatectomy program in a large health maintenance organization setting.

PURPOSE: We present the rapid implementation of a robot-assisted surgery program by one of the largest health maintenance organizations (HMOs) in the United States. MATERIALS AND METHODS: A core group of 10 urologists were offered access to a new da Vinci S surgical system. A core group of five ancillary staff was assembled and trained at an Intuitive Surgical-designated training site. An experienced robotic surgeon acted as a proctor. Data regarding patient demographics, preoperative parameters, operative times, pathologic outcomes, and EPIC-26 quality-of-life questionnaires were collected prospectively and reviewed. All procedures were recorded on digital video disc as part of a quality assurance protocol. The core group reviewed complications monthly and received feedback on surgical techniques and pathologic outcomes. RESULTS: A total of 100 robot-assisted laparoscopic radical prostatectomies were performed from August to October 2008. The patient demographics, preoperative parameters, operative times, and pathologic outcomes of these first 100 procedures are outlined. CONCLUSIONS: We demonstrate the rapid implementation of an efficient multisurgeon HMO-based robot-assisted prostatectomy program with promising initial outcomes.

Decision tree for laparoscopic partial nephrectomy versus laparoscopic renal cryoablation for small renal masses.

PURPOSE: We propose an algorithm to help guide surgeons' decisions between laparoscopic partial nephrectomy (LPN) and renal laparoscopic cryoablation (LCA) based on preoperative parameters and outcomes defined in the literature. PATIENTS AND METHODS: From July 2004 to December of 2007, we performed 51 LPNs and 22 LCAs. We formulated an algorithm between LPN and LCA based on outcomes from published series. Candidates for LPN are younger than 70 years; have few comorbidities; masses < or = 7 cm; and solitary, solid, and or cystic masses with an exophytic or mesophytic location. Candidates for LCA are 70 years old or older, with multiple comorbidities, masses < or = 3.5 cm, multiple masses, solid masses only, and include endophytic or hilar tumors. We then applied this decision tree to our series. RESULTS: Our results for LPN are statistically similar to the published series except there was a higher positive margin rate in our series (11.8 v 3.5%). Our LCA series had older patients (71 v 65 y), larger masses (3.2 v 2.5 cm), and a higher rate of bleeding necessitating transfusion (18%). We applied the algorithm to all 73 patients in our series. It estimated that 45 patients should undergo LPN and 28 should undergo LCA. A correlation between the predicted surgery and the surgery performed was seen, but approximately one in five patients would have a change in the surgery performed. CONCLUSIONS: This algorithm validates decisions surgeons are already making between LPN and LCA. While not a perfect model, it can be used to help simplify decisions between these two minimally invasive procedures to achieve optimal outcomes.